Anyone regularly taking narcotic pain medications (“opioids”) is at risk of an overdose if taking more than 90mg of morphine or its equivalent per day, even if it’s being taken for significant pain.
Morphine 90mg per day is equal to:
Hydromorphone (Dilaudid) 11.25mg per day
Oxycodone (Oxycontin, Percocet, Endocet) 45mg per day
Codeine 200mg per day
Fentanyl (Duragesic Patch) 2.4mg per day (100mcg/hour as a patch)
Opioids depress the central nervous system and, if depressed enough, the person will stop breathing. New opioid prescribing guidelines for non-cancer pain recommend that anyone taking more than 90mg or morphine per day, or equivalent, should have their dosage gradually reduced to the safer 90mg limit. Even lower doses can be risky in some individuals, especially if they are taking other medications that depress breathing. Any drug that causes drowsiness (including alcohol) depresses the central nervous system and breathing. The person may simply look like they’ve fallen asleep…
If you see someone you know or suspect may have taken an excessive amount of narcotic pain medication (legal or illegal) here is what you should look for:
Breathing – slow or absent. May hear choking, gurgling or snoring.
Skin – cold or clammy
Pupils – tiny
Lips – cyanotic (blue)
Lack of consciousness – not responding to sound or touch, can’t be woken up
S.A.V.E.M.E. is an acronym to help you remember what to do.
Stimulate
Airway
Ventilate
Evaluate
Muscular injection
Evaluate again
Here are details of what you should do:
Stimulate: Try to wake them:
Talk loudly: Call their name. Identify yourself. Say “can you hear me?”
Shake them by the shoulder.
Tell them you are going to apply pressure. Rub knuckles vigorously on their chest bone.
Can’t wake them? CALL 911
Stay with the person.
Airway: Check their airway:
Look for chest movement
Tilt head back and listen for breath
If not breathing, ventilate
Use a breathing mask, if available
Pinch nostrils, head is already tilted back as you listened for breathing
Breathe into mouth
Watch that the chest rises and falls
Evaluate:
If not responding, give Naloxone (Narcan) if available
Available as nose spray or as injection (most common)
Muscular injection: How to give an injection of Naloxone:
Prepare the syringe:
Open syringe packaging part way to expose plunger, set aside
Hold ampoule by the pointed top and swirl in a circular motion to collect liquid at the bottom
Snap off the top (direction: away from you)
Remove syringe from package, remove needle cap and draw up all liquid into syringe
Push out excess air (a little air in syringe is OK)
Inject the medication
Insert the needle into a large muscle (meaty part of the thigh, butt, upper arm) like a dart at 90˚ angle (straight in, all the way to the hub), through clothing if necessary.
Press plunger all the way in
Most syringes included in Naloxone kits are safety syringes: pulling back on the plunger will pull the needle into the barrel of the syringe, preventing injury and any need to recap the needle. Other types of safety needles have a built-in system to cover the tip of the needle. If no safety mechanism is available, dispose of the needle and syringe in a glass or hard plastic container to prevent a needle-stick injury.
Evaluate again:
If effective, the person should wake up within 3 – 5 minutes or less
Keep watching the person – the effect can wear off after 20 minutes and you may need to administer Naloxone again, especially if a long-acting opioid was taken.
If no response in 3 – 5 minutes, give Naloxone again.
Repeat until they wake up, the emergency response team arrives, or you run out of Naloxone.
Giving Naloxone when it wasn’t needed won’t hurt the person.
When the person wakes, explain what happened. They may be confused or angry. They may have mild symptoms of opioid withdrawal. Do not allow them to take more narcotics – when the Naloxone wears off, they will have an increased chance of overdose again. Withdrawal effects usually wear off in several minutes.
Wait for the emergency response team. Tell them what you have done. Dispose of needle and glass ampoule in a sharps container (the ER team will have one) or in a bottle with a lid.
A video with detailed instructions is available here.
Adding to the opioid problem, some illegal versions of narcotics sold on the streets are copies made by amateurs that have been found to contain unlabelled dangerous potent drugs like fentanyl. Fentanyl is approximately 100 times more potent than morphine – when potent powders are not mixed to high standards, some tablets can easily contain stronger medication than others. Just a barely-visible speck, not mixed in properly, could provide a fatal amount.
Naloxone kits are increasingly being made available for free through pharmacies in Canada. If you are a caregiver for someone taking more than 90mg of morphine per day (or its equivalent), talk to your doctor about keeping a Naloxone kit on hand. If you work at a youth center or other facility that services youth or adults at risk, keep one or more kits on hand and review their use. It isn’t difficult to administer, and you could save a life…
